Dr JT (Koos) Marais

The patient, a 75 year-old cancer survivor, a retired university professor, was referred to the endodontic practice for the treatment of pain, swelling and discomfort in the left mandible.

Examination showed a fixed bridge, with abutment anchors on the canine, first premolar and second molar and pontics on the second premolar and first molar. (Figure 1)

The soft tissues surrounding the premolar were swollen and tender to touch. Some swelling of the tissues surrounding the canine was also noted. The abutments on both these teeth were clearly leaking. This was confirmed on the radiograph, which showed large peri-apical translucencies and deficient endodontic treatment (Figure 2).

The radiolucency on the premolar was associated with the lateral aspect of the root, next to the large post, highly suggestive of a root fracture. The distal abutment, the second premolar appeared to be strong and sealing(Figure 3).

The situation was discussed with the patient. I told him that the condition of the premolar was beyond treatment, but that I would attempt to treat the canine conservatively by means of a root canal re-treatment.

I then proceeded to remove the bridge, using the Coronaflex instrument from Kavo, fortunately without damage to any of the roots (Figure 4).

I then removed the premolar (Figure 5)

and re-treated the root canal of the canine and temporarily re-cemented the bridge. I suggested to the patient that he consider the placement of implants, "under the bridge", by a specialist, and leaving the bridge and implants until the time of inevitable failure of the bridge. I dismissed the patient with the request to carefully consider my proposal.

I cleaned the extracted premolar of all debris and left it overnight in sodium hypochlorite solution. I was surprised the next morning to see that the root had in fact been intact with no sign of a fracture line (Figure 6).

The lateral surface showed a smooth area clearly showing the portal of exit of a lateral canal. One could reason that the root could have been saved by re-treatment of the root canal and periodontal surgery, but to what end? One would have had to remake the bridge, and that would have been a very costly exercise to follow the equally costly periodontal and root canal treatments. To top it all, the risks of these two weak teeth fracturing would have remained.

At a subsequent appointment, a week later the patient declined my treatment plan of implants. I completed the re-treatment of the root canal (Figure 8)

of the canine and re-cemented the bridge with polycarboxylate cement,  (Figure 9)

asking the patient to immediately advise me if he becomes aware of any mobility or bad smell or taste.

This case is not representative of the ideal treatment plan. I was constrained by the patient's age, medical condition and personal preferences to carry out a compromise treatment. In view of the fact that I had communicated all risks, complications, advantages and disadvantages of all treatment modalities, I am comfortable leaving the patient in a healthy situation, with a fixed bridge, without the extra costs of implant therapy. The long-term success is somewhat doubtful.